2025 CPT code 54800
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Male Genital System Surgery Feed
Needle biopsy of the epididymis for diagnostic purposes.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 22 for increased procedural services, -50 for bilateral procedure). Consult the AMA's CPT coding guidelines and payer specific policies.
Medical necessity for an epididymal biopsy is established when there is clinical suspicion of infection, inflammation, or malignancy based on the patient's history, physical examination, and/or imaging studies.
The physician's responsibilities include preparing the patient (including anesthesia), performing the needle biopsy, obtaining the tissue sample, and closing the wound if necessary.
In simple words: This procedure involves taking a small tissue sample from the epididymis (a tube located behind the testicle) using a needle to help diagnose a medical condition. A local anesthetic is used to numb the area before the sample is removed.Stitches may be needed.
A needle biopsy of the epididymis is a procedure where a small sample of tissue is extracted from the epididymis using a needle. This is done to diagnose various medical conditions affecting the epididymis. The procedure involves preparing and anesthetizing the patient, then inserting a needle into the epididymis to obtain a tissue sample.The needle is then withdrawn, and the puncture site may be sutured.
Example 1: A 35-year-old male presents with scrotal pain and swelling. A needle biopsy of the epididymis is performed to rule out infection or other pathology., A 42-year-old male undergoing infertility workup has an epididymal biopsy to assess sperm production and evaluate potential obstructive causes., A 60-year-old male with a palpable epididymal mass undergoes a needle biopsy for evaluation of malignancy.
* Detailed history and physical examination.* Documentation of the indication for the procedure.* Description of the procedure performed.* Results of the pathology report.* Any complications encountered.* Post-operative care instructions provided.
** Accurate coding requires complete documentation of the procedure and supporting clinical information.
- Revenue Code: P6C (MINOR PROCEDURES - OTHER)
- RVU: This information is not available in the provided sources.Consult the CMS fee schedule for current RVU values.
- Global Days: This is not a global procedure; each biopsy is billed separately.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Fee Schedule: This information is not available in the provided sources.
- Specialties:Urology
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgery Center